The essence of quality health delivery is not just providing efficient and

maintainable care to the patients but also appropriate maintenance of records,

handy in the shortest time. If precise, decipherable and updated medical records
of the patients are not obtainable, it is very difficult for the care providers to agree
on the treatment plan.

t is understood that the patient medical record is the chief source of information
regarding patient care. The medical record is valuable whenever suggestions are
required to protect the service provider on patient care. The customer medium is
mainly dependent on the medical records, whenever there is a medical
negligence incident filed. This is the only record for the doctors to ascertain that
the patient care was approved out as per procedure, during such disagreements.
The insurance companies also need a precise medical record for clearance of
claims. Improper/incomplete record keeping may lead to serious penalties to the
service provider and the patients.

Purpose of medical records

The first and primary purpose of preservation of medical records is to visibly lay
the path way of treatment in order to simplify a methodical and ‘on the track’
action to the patients. As the doctors keep moving from one patient to another, it
is not humanly possible to remember the particulars of all patients. The latest
data, along with the case account of the patient, will allow the facility providers to
work out midterm alterations, if any, and to continue the already laid out
treatment plan. This is a good communication tool for referring, treating, going to
doctors and other care providers. This is the only dependable evidence to verify
that a methodical care has been provided by the doctor and hospital, in the court
of law. The medical records will be valuable for taking many health statistics of
the hospital for analysis and development. These statistical data are not only
useful for hospitals but also to government agencies for many uses. These
records are also useful for patients’ orientation after release and helpful to them
as a defensive tool, in case of any curative negligence. Traditionally, the records
were conserved physically but now it is getting transferred to electronic systems.